DIRECTOR'S COLUMN

Mark Schoenbaum

FIELD REPORTS ON HEALTH REFORM IN THE SAFETY NET

When it comes to Accountable Care Organizations (ACOs) in Minnesota, talk has turned to action. According to a brief from the RUPRI Center for Rural Health Policy Analysis, as of January 2013, 79 Medicare ACOs operated in both metropolitan and non-metropolitan U.S. counties. Medicare ACOs are active in at least 20 Minnesota rural counties.

These ACOs are taking various shapes, including Medicare and Medicaid demonstrations that pay providers a predetermined amount to care for a patient population, tied to quality and cost expectations. Large systems are also rolling out ACO-like performance expectations for their members, whether or not they are formally part of an ACO.

How are these changes affecting independent safety net and small providers? The Rural Health Advisory Committee recently explored this important question for rural Minnesota. In September the Committee heard from PrimeWest Health and Southern Prairie Community Care, two Minnesota pioneers in making collaboration happen among independent safety net providers, as well as from the National Rural ACO, a new multi-state organization.

Both PrimeWest and Southern Prairie are county-owned joint powers organizations, formed in 2002 and 2012 respectively. Now in its 13th year of operation, PrimeWest Health has more than 8,500 providers and over 1,800 facilities under contract to serve its 24,000 members. With integration of medical care and human services central to its identity from the beginning, and acting as a county-based purchasing organization for Medicaid managed care, PrimeWest has many of the characteristics of an ACO.

Though planning a somewhat different model, Southern Prairie will also “coordinate primary care, mental health, dental, and social services through a single health care home, develop regional health information exchanges and promote population health to address community needs” once it begins its contract as a Medicaid demonstration program for the Minnesota Department of Human Services. Both PrimeWest and Southern Prairie place a high value on engaging the independent clinics, hospitals, pharmacists and other providers in their areas.

The urban safety net is also seeing major ACO innovations. In the Twin Cities, 10 safety net clinics have organized themselves into the Federally Qualified Health Center Urban Health Network (FUHN) and have also secured a Medicaid ACO contract. The Commonwealth Fund recently published a case study documenting FUHN’s development. These independent clinics cooperate regularly, but have now taken their collaboration to another level. The case study captures a fascinating story. It suggests the following approaches may be important to developing a coalition or “virtual” ACO:

developing a unified strategy for using data to routinely measure progress and identify improvement opportunities;

prioritizing the development of care coordination infrastructure; and

securing financial investments for care delivery transformation.

Can small and independent safety net providers organize themselves to form ACOs and participate in this rapidly changing environment, or will they be either bypassed or unwillingly acquired as bigger players make their moves? That’s been a central question since the ACO trend emerged. Again according to RUPRI: “the implications of ACOs for rural providers are significant. ACO participants can no longer rely exclusively on a business model that prioritizes service volume as an operational priority. Instead, they must direct attention and resources to increasing clinical quality, improving patient experience, and lowering the cost of care.” RUPRI warns that “ACOs will compete aggressively for patient loyalty, placing non-participating providers at a competitive disadvantage."

Though it’s too early in the experience of Minnesota’s rural and urban ACO pioneers to know whether they’ll succeed in health reform’s big goals - improving population health, enhancing quality and simultaneously controlling costs - evidence is starting to surface that safety net providers can organize themselves, collaborate and get onto the health reform playing field.

Minnesota consultant and writer Arthur Himmelman has categorized the stages of collaboration from preliminary networking, or exchanging information, through true collaboration, in which partners also change how they act, share resources and enhance each other’s capacity to achieve a common purpose. We shouldn’t be surprised that the agility and creativity with which Minnesota’s safety net providers meet their commitments to their communities is again at work in the new world of Accountable Care Organizations.

Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at mark.schoenbaum@state.mn.us or 651-201-3859.

SPECIAL FEATURE

In October, ORHPC released a major new report: Minnesota's Primary Care Workforce, 2011-2012. This month, we asked individuals representing different perspectives in primary care to review the report and respond to four questions. Below is a summary of the responses from our "panelists": Becky Ness, MPAS, PA-C, Professional Practice Chair of the Minnesota Academy of Physician Assistants; Mary Chesney, PhD, RN, CNP, Clinical Associate Professor and Director of the Doctor of Nursing Practice Program at the University of Minnesota's School of Nursing; and Daron Gersch, MD, President, Minnesota Academy of Family Physicians. In addition, we asked Katie Gaul, MA, research associate at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, for her perspective as a national workforce expert. Many thanks to each of you!

[Note: The following is a summary of the responses received from our "panel." Their full responses are available in this Quarterly supplement.]

What are the report's most important findings?

Becky Ness: Physician assistants (PAs), who are all trained in primary care and are a generally younger workforce, can fill the need for primary care providers when given the opportunity as job availability occurs. PAs better represent the state’s increasing ethnic diversity as well. Not addressed in this report is the fact that many PA students desire to go into primary care, but many rural and underserved sites want older and more experienced providers. PA graduates therefore migrate to other specialties as their second option.

Mary Chesney: Of concern is the aging of the physician and nurse practitioner (NP) workforce. Equally concerning is the finding that none of the primary care provider groups adequately match racial and ethnic minority distribution in Minnesota’s population. And rural Minnesota continues to have inadequate access to primary care providers.

The urban-rural distribution of Minnesota NPs is also noteworthy. Nationally, 17 percent of NPs practice in rural areas, where 10 percent of the population resides. In contrast, only 10 percent of Minnesota NPs practice in rural areas, where 17 percent of the state’s population resides. Data from a large 2012 national study (Understanding APRN Distribution in Urban and Rural Areas of the U.S. Using National Provider Identifier Data) showed that NPs were more likely to practice in rural areas in states where NPs had full practice authority (autonomy), compared to states like Minnesota that have restrictions on NP practice. I have also heard from NPs living in rural areas who are not able to practice there because they cannot find a collaborating physician willing to sign the necessary agreement for prescriptive practice.

Daron Gersch: This key sentence is the most important message: “All three provider types provide substantial amounts of Minnesota’s primary care and increasingly work together within certified Health Care Homes and other emerging interdisciplinary, team-based models of care.”

Katie Gaul: This report suggests that, as in many places, there is a geographic imbalance of primary care providers. The lack of diversity in the primary care workforce points to an opportunity to develop new and/or enhance existing diversity initiatives both in the health careers pipeline and in the workplace.

Do any of the findings surprise you?

Becky Ness: There were a number of surprising findings. One is a misperception that NPs have more training than PAs. The report should have provided more emphasis on the robust training of PA’s (27-month programming worth 90-100 credit hours & 2,000+ clinical hours of training). Also, [regarding the challenge of determining how many PAs practice primary care], Certificates of Added Qualifications (CAQs) do not accurately reflect PA practice settings, but American Academy of Physician Assistant (AAPA) data could easily be extrapolated from national data.

Mary Chesney: It was surprising to see a higher proportion of younger primary care NPs planned to stop practicing in Minnesota within the next five years. I am deeply concerned by this finding. Anecdotally, I have heard from a number of our students that they plan to move to states where NPs have full practice authority and where they will be able to fully utilize their skills and knowledge. These younger graduates are not interested in continued battles with organized medicine over scope of practice. Some have expressed concern that they are seeing more institutional restriction on NP practice in Minnesota.

Daron Gersch: I think the report overestimates the people in primary care and therefore doesn't make the shortage seem as bad as it is. I was specifically interested in the numbers of NPs working in primary care, which was less than I expected at 43 percent. It was also surprising that 21 percent of NPs work in rural compared to the percentage of family physicians and internists practicing there. I think the report shows that the NPs and PAs are not going into rural areas to "fill the need." Sadly, it also shows that physicians are not going there either.

Katie Gaul: The PA workforce seems very young and very urban. How likely will this cohort be to move to more rural areas in the future? Also, the number of young family physicians (<35 years) seems low and is a bit worrisome, given that a significant proportion of internists and pediatricians go on to subspecialize and family physicians are more likely to practice in rural areas.

Does anything in the report suggest action needed for the state’s primary care workforce, and if so, what action do you recommend? Who needs to be involved?

Becky Ness: [Strategies should include:] a) Increasing funding for housing in rural and underserved areas for PA students during training, as well as a requirement that rural clinical sites accept students, even if owned and operated by a larger health organization; b) improving tuition reimbursement opportunities for primary care in rural and medically underserved areas to offset salary differences, and allowing for more rural and medically underserved primary care providers in loan forgiveness programs; and c) communication between educational institutions and health care organizations to increase opportunities for PA students interested in primary care employment after graduation.

Mary Chesney: I would like to address the disproportionate racial and ethnic representation among NPs. A higher number of racially and ethnically diverse nurses receive associate degrees (ADs) rather than baccalaureate degrees in nursing. This means they must complete and fund an AD-to-BSN completion program before they can become an NP. We need to find ways to financially support a greater number of diverse students enrolling in baccalaureate nursing programs so the move to graduate NP education can be smoother. A second issue is the restrictive practice environment for NPs in Minnesota. If we want to keep NPs in our workforce and encourage more to practice in rural areas, the Minnesota Legislature needs to enact the APRN Consensus Model, in which APRNs practice to the fullest extent of their education and training.

Daron Gersch: The Minnesota Medical Association (MMA) has a Primary Care Physician Task Force that is currently working to examine and address shortage issues. The Minnesota Academy of Family Physicians (MAFP) has been an active participant, and we encourage the ORHPC to review their results and recommendations. We also suggest tuition incentives for all primary care providers in training, encouraging primary care NPs/PAs to share their experiences working with physicians, and increasing financial support for teaching team-based medicine in schools. The Robert Graham Center identifies these potential ways to bolster the primary care pipeline: physician payment reform, dedicated funding for primary care graduate education funding, and increased funding for primary care training and medical student debt relief.

Katie Gaul: It is difficult to attract health care professionals to rural and underserved areas for a variety of reasons. Suggestions for action include evaluating recruitment and retention efforts, determining how many graduates stay in state, practice in primary care and practice in rural areas, and investigating new training strategies. Studies show that a racially and ethnically health workforce is also important in maintaining accessible, equitable and culturally competent health care. Potential strategies include expanding loan repayment, pipeline initiatives, fostering cultural competence in education programs, attracting more diverse faculty, strengthening student support programs, and tracking and evaluating pipeline data to monitor trends.

Do you see any trends regarding the availability and distribution of primary care, or models that are working elsewhere?

Becky Ness: In Michigan, the Department of Health used tobacco settlement funds for student scholarships to help offset housing and travel expenses for rural training experiences. It was a win-win for students and communities.

Concerning trends in Minnesota include the number of rural health clinics merging with larger health care organizations. These organizations are looking at productivity measures, as well as self-imposed screening measures for potential students, which limit exposure and access to educational partnerships. There is also a common misconception among health care administrators on the role and scope of practice for new PA graduates, who are very well equipped to provide quality primary care, especially in rural Minnesota.

Daron Gersch: I see fewer providers going into primary care. Ten to 15 years ago it would take six months to a year to recruit someone to our clinic, now it is two to three years. Even in family medicine, more people are going into emergency or hospital medicine. PAs and NPs are working more with other specialties versus going into primary clinical care.

Everyone talks about getting more money to primary care, but it is not happening. Until this infusion of money occurs there will continue to be a shortage. Some states have a per-patient-per-month payment that has been very successful in getting money to primary care clinics - we need to do the same.

Katie Gaul: Under the Affordable Care Act (ACA), the health care system is transforming workforce needs. Its emphasis on preventive care, as well as changes in payment policy, are likely to shift care to ambulatory, community and home-based settings. This will require new health care roles and may affect how existing workers practice in teams to deliver care.

Project Echo, through the University of New Mexico’s School of Medicine, promotes care in underserved areas. Minnesota’s own community paramedic training initiative is another model.

From Nitika Moibi, Supervisor of ORHPC’s Health Workforce Planning and Analysis program:
Thanks to each of you for sharing your perspectives. As we reviewed the data for this report, every number told a story of lack of geographic access and diversity, aging providers and primary care deserts. Addressing these challenges is complex, as your thoughtful answers confirm, but more important than ever. The success of health reform rests on what the Institute on Medicine stated so well back in 1996: “Primary Care is the logical basis of an effective health care system.”

Our collective challenge is to bend the curve, so that the right mixes of providers are in the right places to serve Minnesotans. Here at ORHPC and MDH, we will continue to share data responsibly, inform dialogue, and forge partnerships to accomplish that. We look forward to working with you, and thanks again.

PROGRAM FOCUS

SUICIDE IN RURAL MINNESOTA: WHAT WE CAN DO

by Will Wilson

Over the last few years, suicide has spiked again in Minnesota - especially in rural communities. In 2011 alone, the number of suicides rose by 13 percent, the steepest increase in over a decade. The incidence of suicide in non-metro areas accounted for much of that increase.

The point of this article, however, is not to bemoan the rise in suicide in rural Minnesota. The goal here is to share some evidence-based strategies, make connections to groups working to prevent suicide, and highlight ideas that can be implemented for little or no additional cost. Suicide is preventable, and there are ways everyone can help.

First, though, more statistics to place suicide in its proper context. According to our own MDH data, Minnesota had 684 suicides in 2011 - a spike upward consistent with preliminary 2012 data as well. This means suicide is the 10th leading cause of death in Minnesota, and responsible for over three times more deaths than homicide.

The public discussion of suicide tends to focus on teens. However, while teen suicide is certainly a major concern - suicide is the third leading cause of death among adolescents - the data show that by sheer number, the true face of suicide is predominantly middle-aged, rural and male. Firearms are the method of roughly half of suicides in the state, most often among men. Poisoning (usually with medications) is the second most common method, more often among women.

Suicide rates outside the seven-county metro area are considerably higher (14.3 per 100,000) compared to the metro counties (10.9 per 100,000). Males are four times more likely (18.0 per 100,000) to commit suicide than females (4.5 per 100,000). And males in greater Minnesota account for the highest rate, at 23.0 per 100,000.

Again, suicide is preventable.

Resources available

Suicide Awareness / Voices of Education (SAVE), a current grantee from the MDH Suicide Prevention Program, reports that “90 percent of those who die by suicide were suffering with an underlying mental illness or substance abuse problem at the time of their death.” Reaching those suffering from mental illness - particularly depression - is a key prevention strategy. The good news: over 80 percent of people who seek treatment for depression are treated successfully. SAVE offers a wealth of factual information to de-mystify suicide, as well as brochures and publications designed to target specific audiences.

Training and education programs for front-line medical staff, administrators and even the general public are another good strategy. The National Alliance on Mental Illness in Minnesota (NAMI-MN), another MDH grantee, hosts trainings around the state related to suicide prevention. One such training is called “Question, Persuade, Refer” - or QPR. The idea of this one-hour course is to teach emergency response techniques for connecting someone who is in crisis to help. You can call NAMI for more information on this course, at 888-626-4435.

Another good education program that looks broadly at mental health in communities is called Mental Health First Aid. The goal of the program is to build capacity in communities for identifying mental illness, and to encourage people to seek more information and help for their condition. Anyone can take the course. One-day, 8-hour Mental Health First Aid seminars can be arranged through certified trainers listed on the program’s website. A rural-specific Mental Health First Aid program will be available soon; stay tuned to the Rural Mental Health First Aid Kit web page.

For rural health care providers, one cost-effective, easy way to identify patients in need of mental health services is to screen for depression in the primary care setting. For example, the Patient Health Questionnaire, or PHQ-9 is a quick, evidence-based screening instrument commonly used in primary care clinics to screen for potential symptoms of depression. The PHQ-9 can also be used as a baseline to track progress and outcomes over time. The Integrated Behavioral Health Project describes other effective screening tools in its recently updated Integrated Behavioral Health Screening Tools for Primary Care publication.

If someone is considering suicide, referring them to help is the first step. The National Suicide Prevention Lifeline is 1-800-273-TALK (8255). There are also several crisis hotlines around the state connected to local agencies - contact your local community health board for information on organizations in your area. For those who prefer it, a text-oriented services known as TXT4Life responds when teens or others text the message “LIFE” to the number 839863.

For more serious crises, mental health crisis service programs are available in every county of the state. The Minnesota Department of Human Services (DHS) maintains a Crisis Numbers list with the phone numbers of every program in the state, both for children’s and adult mental health crisis services. DHS reports that in 2011, 11,483 adult mental health crises and 10,034 child mental health crises were managed by mental health crisis services in Minnesota. This service is growing, with new state funding passed in the 2013 Legislative Session.

Finally, new evidence is emerging that for people who have attempted suicide, reaching out with subsequent contacts - something as simple as a reminder card for a follow-up visit - can significantly reduce the risk of additional suicide attempts. This may seem counterintuitive, as you may think someone would be ashamed of thinking about a suicide attempt, but the evidence is clear: establishing and maintaining these connections greatly reduces the risk of additional suicide attempts.

And perhaps that is the most important point: the less isolated people considering suicide feel, the more likely it is they will get better.

One last piece of information: the MDH Suicide Prevention Program will be revising the statewide suicide prevention plan in the coming months. If you are interested in participating, contact our office. And if you have any questions about this article, or would like contacts to the organizations mentioned above, please contact me.

Will Wilson is supervisor of financial and technical assistance programs at the Office of Rural Health and Primary Care. Will can be reached at will.wilson@state.mn.us or 651-201-3842.

RHAC PROFILE

I have staffed the Rural Health Advisory Committee for nine years. I organize the bi-monthly meetings and help develop the committee’s work plan. I do research and policy analysis based on the committee’s priorities. My previous jobs at the Minnesota Department of Health included working with local public health departments and survey work on a serious work-related injury study.

And your life away from work?

Yoga and meditation are important to me and provide balance in my life. I have a Yorkie named Fergie Lou who keeps me active. I also stay busy with volunteer work, most recently through The Birthing Project, a pilot project through Twin Cities Healthy Start. I provide support and encouragement to my young sister-friend who just became a parent to a baby girl. I also volunteer for Kids Voting in the Powderhorn neighborhood of Minneapolis and as a community radio consultant for Niijii Radio in White Earth. When I want to cut loose, I play bass with my alt-country band called Global Prairie Rock. My niece and nephews are my pride and joy, and I will soon be an auntie again for the fourth time.

What do you think are the most important issues facing rural health?

Health Care Reform. Many rural health providers are already practicing team-based, patient centered care. We need to make sure new payment methodologies and regulatory structures work for rural areas. It is important to minimize the differences in standards of care based on geography while acknowledging that unique challenges exist for rural health care.

Health Equity. While the Affordable Care Act has made health care more accessible, many rural residents will fall through the cracks. People who struggle with mental illness, generational poverty, or housing and food insecurity continue to suffer from ill health. As a state, we can decide this is unacceptable and take collective action on the social determinants of health. As the late, great Senator Paul Wellstone said, “We all do better when we all do better.”

What do you think would make the most difference for rural health?

Rural health needs bold leadership in these times of great change for health care. New challenges related to health reform create uncertainty. Longstanding challenges related to access and workforce issues will continue in rural regions. We need leaders who are visionary, willing to engage in difficult conversations, and determined to never give up as advocates for rural and underserved areas. We need rural ideas and voices at the table as federal and state policy decisions are made.

The Rural Health Advisory Committee advises the commissioner of the Minnesota Department of Health and other state agencies on rural issues; provides a systematic and cohesive approach toward rural health issues; and encourages cooperation among rural communities and providers. Meeting information is online.

MISSION: To promote access to quality health care for all Minnesotans. We work as partners with policymakers, providers, and rural and underserved urban communities to ensure a continuum of core health services throughout the state.